Volume 36, Number 2
MARCH/APRIL 2014
Page 3
Health Care Reform
Meeting the Needs of the
Newly Insured
Page 4
Pneumococcal Vaccination:
Identifying Barriers and
Strategies to Improve
Administration Rates
Free education activity for
AAACN members!
Page 9
Telehealth Trials &
Triumphs
Between a Rock and a Hard
Place
Page 10
In late spring 2013, the AAACN Board of Directors chartered a task force to “develop
and identify nurse sensitive processes and outcomes indicators related to the role of the
registered nurse in ambulatory care.” This important work supports the AAACN strategic
plan. The task force began its work by examining what measurements already exist, brainstormed about what measurements were necessary but missing, and how to identify
measures that capture the ambulatory nurse’s increasingly crucial role in health care
redesign and transformation.
The task force identified the need to build upon the strong body of work of Care
Coordination and Transition Management led by Drs. Beth Ann Swan and Sheila
Haas and Traci Haynes (2013). Additionally, the task force gleaned knowledge from
Dr. Nancy Dunton, ANA’s representative on the task force, for an overview of the
development and implementation of nurse sensitive indicators (NSIs) by the National
Database of Nursing Quality Indicators (NDNQI). Further conversations looked at the
Centers for Medicare and Medicaid Services, Physician Quality Reporting System
(PQRS) indicators and other important entity measurements such as those from
National Quality Forum (NQF) regarding care coordination measures. The task force
selected the Donabedian (1966) framework of structure, process, and outcomes to
organize future ambulatory indicators.
Part of the task force’s work was to develop critical filter questions to assist in the
selection of the strongest indicator(s) for ultimate success and recommendation to
the AAACN Board. Task force members articulated selecting indicators that are:
continued on page 12
The Official Publication of the American Academy of Ambulatory Care Nursing
Safety Corner
Cystoscope Reprocessing Safety
Page 13
Health Policy Update
Researching the Scope of
Practice for Medical Assistants
NOW Available!
Care
Coordination
and Transition
Management Course
See Insert
for Details
Happy Nurses Week!
At this time of year, we honor
our members and colleagues for the
care, kindness, guidance, and support they give to every patient.
Nursing continues to be one of the
most trusted professions and there is
a reason for that – YOU! Be sure to
do something special for yourself
during the week of May 6-12.
Submit your stories and photos of
how you celebrated by sending an
email to [email protected].
Greetings from your
Board of Directors!
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A
After what has seemed to be a very long and cold winter, spring is finally on the horizon and we look forward to
the colors and sounds that announce the change of season. Spring is always an exciting time for AAACN as we
continue to work on our strategic plan and initiatives to
serve our members, expand our influence, and strengthen
our core, as we anticipate coming together for the annual conference. And there are more of us than ever! AAACN
reached a milestone at the end of 2013. More than 1,800
members renewed in December and we had the most
Susan M. Paschke
new members ever at 1,201! Today we are 3,031 members strong and growing!! What a great testament to our organization and our
members! Ambulatory nurses join AAACN to connect with others in similar roles
and to network about common problems and solutions, to advance their practice and leadership skills through opportunities to collaborate with other leaders
and mentors, and to advocate for the specialty of ambulatory care nursing locally and nationally.
Retention of current members and recruitment of new members, especially
those of the more recent generations, is and has been one of our strategic objectives for the organization. The board has been discussing leadership development
of the new and emerging leaders of AAACN and succession planning for the
future. This will be a theme of our board meeting in New Orleans. If you want to
be part of the leadership of the future, find a way to get involved with the organization. Join a committee, SIG, or a task force. Prepare a poster or podium presentation for the annual conference. Become involved in a local networking group
or start one in your area. You may not desire to be a board member or the president, but there are plenty of leadership opportunities outside of those roles.
Remember, as ambulatory care nurses, we are all leaders!
I had the pleasure of participating in a first for the nursing organizations that
are managed by Anthony J. Jannetti, Inc. The leaders of six nursing organizations
participated: AAACN, Academy of Medical-Surgical Nurses (AMSN), American
Nephrology Nurses’ Association (ANNA), American Nursing Informatics
Association (ANIA), Gerontology Advanced Practice Nurses Association (GAPNA),
and the Society of Urology Nurses and Associates (SUNA). Each organization provided information about their members and the major issues they are concerned
about: low membership, engaging younger members, and developing new leaders. Opportunities for collaboration were discussed with the following suggestions brought forward: consider sharing speakers, making our Online Libraries
available to each other, sharing technology best practices, and pursuing joint
marketing of programs and products through our e-newsletters. Leveraging our
resources and sharing the expertise of colleagues is a great first step. Further conference calls and discussions about future collaboration are planned.
Collaboration is an important concept for AAACN this year. The first
Ambulatory Care Certification Intensive CE Series in partnership with Gannett
Education was offered in January and February. Approximately 60 participants
engaged in five webinars and completed four reading modules in preparation to
take the Ambulatory Care Certification exam. The series was so successful that
four more series are planned for 2014. In addition to the Ambulatory Care
Certification review course offered at the annual conference and at various sites
2 ViewPoint MARCH/APRIL 2014
continued on page 15
View health care reform resources online at:
www.aaacn.org/health-care-reform
Meeting the Needs of the
Newly Insured: A Look at the
Numbers
The title of a recent article from Kaiser Health News
(KHN) (Ollove, 2014) posed the question, “Are There
Enough Doctors for the Newly Insured?” A news article
with such a title is misleading. The article was stimulated by
a story in Stateline, the daily news service of The Pew
Charitable Trusts. Unfortunately, this headline and the article content create a false impression that we will continue
with Medical Model health care where the pivotal provider
is a medical doctor. However, the Affordable Care Act
(ACA, 2010) provisions are designed to foster wellness,
health promotion, and disease prevention though interprofessional provider teams working collaboratively in
Patient-Centered Medical Homes (PCMH) and
Accountable Care Organizations (ACOs), whereas the
Medical Model focuses on physician diagnosis and treatment of acute and chronic illnesses. Missing in the headline as well is the acknowledgement that health care also
involves other primary care providers such as nurse practitioners, physician assistants, pharmacists, social workers,
dieticians, dental specialists, and mental health care
providers who focus on prevention of disease and promotion of wellness. Such providers are also members of interprofessional teams providing care for the newly insured.
The KHN article (Ollove, 2014) also provides statistics
derived from the U.S. Department of Health and Human
Services, Health Resources and Services Administration
(HRSA, 2014) regarding the numbers of providers needed
to improve access to health care. These numbers demonstrate that there will be access issues for the newly insured.
“Nearly 20% of Americans live in areas with an insufficient number of primary care doctors. Sixteen percent live in areas with too few dentists and a whopping 30% are in areas that are short of mental health
providers. Under federal guidelines, there should be
no more than 3,500 people for each primary care
provider, no more than 5,000 people for each dental
provider; and no more than 30,000 people for each
mental health provider” (Ollove, 2013, 2014, p. 1;
HRSA, 2014).
Again, this information does not view providers
through a broad lens; instead, the focus is on the traditional view of doctors, dentists, and psychiatrists and how
shortages of these providers will hamper access for the
newly insured. The following reinforces this view: “Many
primary care doctors and dentists do not accept Medicaid
patients because of low reimbursement rates...and many
psychiatrists refuse to accept insurance at all” (Ollove,
2014, p. 1). It is not until page 3 of the article that
advanced nurse practitioners (APNs), physician assistants
(PAs), and pharmacists are mentioned as potential primary
care providers, even though the ACA (2010) provisions list
them as primary care provider members of the interprofessional team. The lead-in to a discussion of alternative primary care providers begins with, “A more controversial
idea is to allow nurse practitioners, physician assistants,
pharmacists, and dental aides to do some of the work usually reserved for doctors and dentists. Many states have
passed such legislation while other are eyeing similar measures” (Ollove, 2014, p. 3). The KHN article also states that
the American Dental Association opposes use of mid-level
dental workers, even for routine preventive and restorative
work, and some groups representing physicians are resisting allowing APNs to write prescriptions and admit
patients to the hospital. Polly Bednash, Executive Director
of the American Association of Colleges of Nursing,
responded to such resistance with, “Health care is not a
zero-sum game where there is a limited amount of care to
be given. If there’s more care needed than we can deliver
in the world, we have to decide who else can provide quality care” (Ollove, 2014, p. 3).
What is needed in health care today to meet the needs
of the newly insured is visionary thinking and innovation.
We cannot afford to deliver Medical Model health care
using fee-for-service methods. Rather, we need to consider
outcomes that need to be achieved; methods to deliver
disease prevention, wellness, and health promotion; as well
as acute and chronic disease care and valid and reliable
measures of processes and outcomes.
The Institute of Medicine’s (IOM) report, The Future of
Nursing (2010), demonstrated such visionary thinking with
its recommendations. It speaks directly to the topics in this
column.
• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and
training through an improved education system that
promotes seamless academic progression.
• Nurses should be full partners, with physicians and
other health care professionals, in redesigning health
care in the United States.
• Effective workforce planning and policy-making
require better data collection and an improved information infrastructure.
As you know, AAACN has been working over the past
18 months to develop the dimensions, competencies, and
a model of Care Coordination and Transition Management
(CCTM) (Haas, Swan, & Haynes, 2013). This work on the
continued on page 11
WWW.AAACN.ORG 3
Instructions for
Continuing Nursing
Education Contact Hours
Pneumococcal Vaccination:
Identifying Barriers and Strategies to
Improve Administration Rates
Deadline for Submission: April 30, 2016
To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact
hours, you must read the article and complete the evaluation online in the AAACN
Online Library. ViewPoint contact hours
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• Read the ViewPoint article of your choosing, complete the online evaluation for
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The purpose of this continuing nursing education article is to inform ambulatory care nurses
and other health care professionals about the
real and perceived barriers to vaccinating those
at risk for streptococcus pneumonia, which
results in more deaths than any other vaccinepreventable disease in the United States, and
how organizations can put into place interventions to increase pneumococcal vaccination
rates. After studying the information presented
in this article, you will be able to:
1. Discuss the indications and contraindications for the pneumococcal polysaccharide
vaccine (PPSV).
2. Identify barriers that impact pneumococcal
vaccination administration.
3. Explain two proven nursing interventions to
improve pneumococcal vaccination rates.
4. Describe how nurses can influence health
promotion and disease prevention by
championing immunizations.
The author(s), editor, and education director
reported no actual or potential conflict of interest in
relation to this continuing nursing education article.
This educational activity has been co-provided by
Anthony J. Jannetti, Inc. and AAACN.
AAACN is provider approved by the California Board
of Registered Nursing, provider number CEP 5366.
Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.
Anthony J. Jannetti, Inc. is accredited as a provider
of continuing nursing education by the American
Nurses Credentialing Center's Commission on
Accreditation.
4 ViewPoint MARCH/APRIL 2014
Pneumococcal Vaccination:
Identifying Barriers and
Strategies to Improve
Administration Rates
Melly Turner
Cherie Parks
Felicia Murphy
Laura Dick
Cherie Chaney
Streptococcus pneumonia results
in more deaths than any other vaccine
preventable disease in the United
States. Most deaths related to pneumococcal disease occur among older
adults with underlying chronic conditions (Szilagyi et al., 2005). Case fatality rates are high, especially when the
disease results in meningitis or bacteremia (Atkinson & Kroger, 2011).
The advent of an increased number of
aging “baby boomers,” people living
longer with chronic disease and the
emerging problem of antibiotic resistance have added to the population at
risk for pneumococcal infection.
Streptococcus Pneumoniae bacteria is a major cause of the 900,000
cases of community-acquired pneumonia in the US each year and
approximately 175,000 people are
hospitalized annually with the infection. In addition, concurrent cardiac
events are common among patients
hospitalized with pneumococcal
pneumonia. It is also a major cause of
milder common illnesses such as
sinusitis and otitis media (Nuorti,
2011). The bacterium is transmitted
directly from person to person by respiratory droplets and can cause lifethreatening illnesses such as meningitis, bacteremia, and pneumonia
(Nuorti, 2011). Symptoms can suddenly develop and vary by clinical
presentation. Pneumonia symptoms
include fever, shaking, chills, cough,
shortness of breath, and chest pain. In
the elderly, symptoms may be atypical
and might include weakness or confusion without the presence of a fever or
other more common symptoms (Facts
about pneumococcal disease and prevention in adults, 2011).
Prevention of streptococcus pneumonia begins with vaccination. The
Immunization
Action
Coalition
(Atkinson & Kroger, 2011) recognizes
FREE
Continuing Nursing
Education
Kathryn Ward
Suzanne M. Burns
the following “at risk” populations for
which the pneumococcal polysaccharide vaccine (PPSV) is indicated:
• Previously unvaccinated adults age
65 years of age and older
• Age 2-64 with any of the following
conditions:
a. cigarette smokers age 19 and
older
b. functional or anatomic asplenia
(e.g., sickle cell disease, splenectomy)
c. immunocompromising conditions (e.g., HIV infection, leukemia, congenital immunodeficiency,
Hodgkin’s
disease,
lymphoma, multiple myeloma,
generalized malignancy) or on
immunosuppressive therapy
d. organ or bone marrow transplantation
e. chronic renal failure or nephrotic syndrome
f. chronic cardiovascular disease
(e.g., congestive heart failure,
cardiomyopathies)
g. chronic pulmonary disease (including asthma in people age 19
and older)
h. cerebrospinal fluid leak
i. diabetes mellitus
j. alcoholism or chronic liver disease (cirrhosis)
k. candidate for or recipient of
cochlear implant
Pneumococcal Vaccination
The PPSV is a sterile liquid vaccine
that may be given either by intramuscular (IM) or subcutaneous (SC) injection. When administration is IM, the
nurse chooses needle length as appropriate to the person’s age and body
mass. In adults, the standard needle is
1–1½” long. A 5/8” needle may be
used for adult patients weighing less
than 130 lbs (60 kg) for IM injection in
the deltoid muscle only if the subcuta-
Table 1.
Consumer and Health Care Providers’ Explanations
Why Adults May Not Receive the Pneumococcal Vaccine
Consumer Reasons for
Not Getting Immunized
Health Care Provider Perceptions of
Why Patients Don’t Get Immunized
“Was healthy so don’t need it.”
“Lack of knowledge about illness
prevention.”
“Think healthy people don’t need it.”
“Doctor didn’t tell me I needed it.”
“Not receiving physician’s
recommendation.”
“The vaccine may have side effects.”
“Could interact with medication.”
“Concern about side effects.”
“Don’t know when to get it.”
“Unaware of the schedule.”
“May not work well.”
“It will cause illness.”
“Dislike needles or shots.”
“Fear of needles.”
“Might get the disease.”
“Confused about recommended
vaccination schedule.”
“Could worsen current conditions.”
“Lack of knowledge about illness
prevention.”
“Insurance doesn’t cover it.”
“No effective reminder system.”
“Inadequate insurance coverage.”
“Don’t visit a doctor regularly.”
“Patient does not make regular well
visits.”
“Not going to the same physician
regularly.”
“Costs too much.”
“The vaccine is too expensive.”
Source: Adapted from Johnson et al., 2008.
neous tissue is not bunched and the
injection is made at a 90-degree
angle. When administration of PPSV is
SC, a 5/8” needle is recommended.
The timing of vaccine administration
is also important. The vaccine should
be given at least two weeks before
elective splenectomy and the initiation of immunosuppressive therapy,
and avoided during chemotherapy or
radiation therapy. The vaccine may be
administered at the same time as the
influenza vaccine but by separate
injection in the opposite arm. The
most common adverse reactions
reported are local reactions at the
injection site including soreness,
warmth, swelling and induration as
well as a fever less than 102 degrees
Fahrenheit. It is contraindicated for
anyone who has a hypersensitivity to
any component of the vaccine.
Epinephrine injection (1:1000) must
be available should an acute anaphylactic reaction occur due to any component of the vaccine. All significant
adverse events that occur after vaccination of adults, even if there is uncertainty about whether the vaccine
caused the adverse event or not,
should be reported to the Vaccine
Adverse Event Reporting System
(VAERS).
The vaccine for pneumonia is safe
and cost effective. According to CDC
records, in 2011 VAERS received 2,071
reports of adverse events in persons
vaccinated with the pneumococcal
vaccine (G. Redmond, personal communication, May 17, 2013). The
VAERS report indicates that the
adverse events occurred after the
administration of the vaccine and
were not necessarily caused by the
vaccine itself. Although the vaccination is considered safe and only a
small minority of patients experience
an adverse drug reaction, it is essential
that precautions are noted. For example, it is important to note that
there is a higher incidence of systemic adverse reactions, following
revaccination in patients 65 years or
older. Furthermore routine revaccination of immunocompetent persons previously vaccinated with a
23-valent vaccine is not recommended (Merck and Company,
2013). Despite the potential risk, in
most cases, the vaccine is much less
costly than the disease itself. The average cost of pneumonia care for
Medicare beneficiary patients from
2005-2007 was $10,266 with a range
of $3,341 to $17,192 (Thomas et al.,
2012) as compared to the cost of the
vaccine, which is $64.22 per dose
(Merck Global Health Division, 2013).
The vaccine and administration
costs are typically covered by
Medicare and most major insurance
companies. The Centers for Disease
Control indicate that PPSV vaccine is
60%-80% effective against invasive
pneumococcal disease when it is
given to people age 65 years and
older or people with chronic illnesses.
The vaccine is less effective in those
patients who are immunosuppressed
(Atkinson & Kroger, 2011). However,
the number of older adults (age 65
and older) who received the vaccine
was 61% in 2008, which is below the
90% target for 2020 Healthy People
goals (U.S. Department of Health and
Human Services, 2010). Despite the
fact that the vaccine is universally
available, patients who are seen by
health care providers are not requesting the vaccine and clinicians who
interact with them do not appear to
be recommending it (Gooden, 2010).
Barriers to Vaccination
The barriers to adult immunization commonly fall into three categories: lack of knowledge about
WWW.AAACN.ORG 5
Figure 1.
New Knowledge Post Intervention
immunizations, fears about vaccine
safety, and logistical problems that
limit access to immunization (Burns &
Zimmerman, 2005). Similarly, health
care providers also encounter barriers
such as: lack of knowledge regarding
indications and contraindications to
immunizations, costs of immunizations, difficulties in vaccine storage or
availability, lack of access to a patient’s
prior immunization records, and
missed opportunities to administer a
needed immunization during a clinic
visit (Burns & Zimmerman, 2005).
Although the evidence shows that
most patients will receive vaccinations
if recommended by their health care
provider, such recommendations are
not routinely made (Gooden, 2010).
Lack of awareness also plays a role
in missed vaccinations. In a study of
Medicare beneficiaries, lack of awareness was the most common response
cited for not receiving the pneumococcal vaccine (Gooden, 2010).
Rangel and colleagues (2005) showed
that lack of awareness, as well as personal beliefs, were significant barriers
to vaccination. It is also possible that
socioeconomic and educational levels
play an indirect role as barriers to vaccination (Gooden, 2010).
Johnson, Nichol, and Lipczynski
(2008) conducted a survey focused on
determining barriers to pneumococcal
vaccinations as reported by 2002 consumers and 200 health care providers.
The reasons cited by both groups for
not receiving the pneumococcal
6 ViewPoint MARCH/APRIL 2014
immunization are listed in Table 1.
Interestingly, the health care providers
perceptions of why individuals do not
get immunized closely mirrors the reasons provided by the consumers
(Johnson et al., 2008).
Methods
Combining knowledge learned
from the Johnson survey with a goal of
preventing pneumonia in their highrisk patient population, a cardiology
clinic in an academic center focused
on discovering in their own practice
setting, potential or real vaccination
rate barriers. Furthermore, the
Johnson study provided a tool to
assess knowledge base; therefore it
was an appropriate survey to replicate. In an effort to assure that pneumococcal vaccines are appropriately
provided to patients in a heart and
vascular outpatient clinic, a derivative
of the Johnson survey was distributed
to determine the perceptions of registered nurses and nurse practitioners
regarding barriers to patient pneumococcal vaccination and nurses’ knowledge about the existing vaccine
guidelines.
The study survey focused on current practice norms and perceived
barriers and beliefs. The questionnaire
had two sections: Practice and
Knowledge. A variety of questions
were used such as multiple choice,
True-False, Yes-No, and some used a
five-point Likert scale with the points
of strongly agree and disagree. The
Practice section consisted of thirteen
questions that were adapted from the
Barriers to Adult Immunization Survey
with permission of Johnson and coauthors (2008). The Knowledge section included an additional ten questions, developed by the research
team, to assess the nurses’ knowledge
of the following pneumocococcal vaccine topics: indications, administration, revaccination, immunity timeline, adverse experiences, and
treatment of anaphylactic reaction.
The study was conducted by providing a confidential, electronic questionnaire to all nurses and nurse practitioners who worked in the heart and
vascular clinic using no identifiers.
Twenty-two nurses were sent the
questionnaire and the response rate
was 100%.
Survey Findings
The survey findings of the clinic
nurses’ perceptions regarding the barriers to immunization that patients
experience were consistent with those
found in the literature. The top seven
responses (listed below) regarding
these barriers fit into the categories of
lack of knowledge, fears about vaccine
safety, and logistical problems that
limit access.
1. Patients may not be aware of, or
are confused by, the vaccination
schedule.
2. Some patients may believe the
vaccine has side effects or will
make them sick.
3. Patients may not understand the
seriousness of pneumococcal
pneumonia.
4. No effective reminder system for
the patients was in place.
5. Patients may believe that healthy
people do not need the vaccine.
6. Not receiving a physician’s recommendation.
7. Not going to the same physician
regularly and thus follow-up was
not present.
In the same survey, respondents
estimated that during routine office
visits approximately 33% of patients
received the vaccine as a result of a
recommendation. Seventy-two percent of the nurses reported “sometimes” discussing the possible conse-
Figure 2.
Staff Response to “Somewhat/Strongly Agree the Intervention Had a
Positive Effect on Your Knowledge and/or Practice”
In eight out of thirteen interventions
to address knowledge deficits, staff
ranked 50% or greater that they “somewhat/strongly agree the intervention
had a positive effect on their knowledge
and or practice (see Figure 2).
All strategies of the intervention
program are now embedded in the
cardiology clinic practice. The success
of this program is determined by following, on a monthly basis, the vaccination compliance rates.
Organizational Response
quences of pneumonia if not vaccinated. And finally, only 32% of the nurses were familiar with the ACIP guidelines.
In concert with the findings of
Johnson and colleagues (2008), the
survey results suggest there is a need
to increase patient awareness and
nurses’ knowledge of the pneumococcal vaccine. Gooden (2010) concurs
and further suggests that “what does
or does not happen in the doctor’s
office may be shaped by the patient’s
knowledge and attitudes, the personal beliefs and priorities of the clinicians
working with the patients; the way
the practice is managed, perceived
barriers, and the broader policy environment established by health care
systems and governments” (Gooden,
2010 p. 2).
Interventions and Results
As a follow up to the survey
responses, the authors developed a
nurse led, multifaceted intervention
program to address knowledge
deficits and determine if the interventions would increase vaccination rates.
These interventions consisted of incorporating standing protocol vaccine
orders, educating nurses on the current ACIP guidelines through weekly
in-services, providing a pocket guide
with related pneumococcal vaccine
information, and creating a script for
nurses to use with each patient
encounter, which comprehensively
covered the importance and benefits
of immunizations. Involving patients
in the process was also important as
was providing Vaccine Information
Sheets (VIS) to patients during rooming in and displaying informational flyers in each clinic room. Informational
posters were also displayed in additional prominent clinic locations to
increase patient interest in vaccination
and prompt them to ask about the
vaccine. Additionally, a reminder system that included vaccine-specific
information with mailed appointment
notices, as well as adding a reminder
to the office or nurse(s) voicemail
greeting assisted in increasing this
awareness of and demand for immunization.
To determine the effectiveness of
our intervention program, the initial
survey was re-administered with the
addition of a six-point Likert scale having the end points of strongly disagree, somewhat disagree, neither
agree nor disagree, somewhat agree,
strongly agree, and don’t know.
Nurses were asked to use this scale to
evaluate the effect of each intervention on their knowledge and practice.
New Knowledge Results
In eight out of ten knowledge categories, there was marked improvement. The most dramatic was familiarity with the ACIP guidelines rising
from 32 % pre intervention to 65%
post intervention. The second largest
knowledge gain was related to the
importance of vaccinating patients
19-64 years of age who are smokers or
have asthma (see Figure 1).
The health care system established
a vaccination task force to explore
strategies to increase Influenza and
Pneumococcal vaccine administration
compliance. The task force administered a survey to nursing staff throughout the ambulatory care clinics that
focused on current practice norms,
perceived barriers and beliefs. The survey results were similar to the heart and
vascular clinic survey results regarding
knowledge deficits and perceived versus actual administration compliance
rates. To reduce the knowledge deficit
and better inform all nursing staff, an
article on Pneumococcal vaccination
indications and clinic results was published in the health system’s nursing
practice newsletter. Two actionable
items derived from the survey results
were incorporated into the electronic
medical record. A hyperlink was established from the electronic medical
record to the CDC’s Vaccine
Information Sheet website. This assures
the most current patient information is
easily available. Additionally, a pathway
was created to support a standardized
process for documenting patient
refusals of vaccinations. Additional
action plans are also underway. A computer based learning module focusing
on Influenza and Pneumococcal vaccinations is being developed. An electronic medical record vaccination
reminder is in production. The
reminder will alert clinicians when indications for the Pneumococcal vaccine
are met. Furthermore, additional refrigerators are being stationed directly in
the clinics to facilitate Influenza and
Pneumococcal vaccine storage and
ease of obtaining these necessary vaccines.
WWW.AAACN.ORG 7
What Can Nurses Do
The Community Guide, developed
in 2000 as an evidence-based Guide
to Community Preventive Services,
outlined recommendations regarding
interventions to improve vaccination
in children, adolescents and adults
(Ndiaye et al., 2005). These interventions are categorized as those that are
provider- or system-based, enhance
access, or increase demand for vaccinations. This guide serves as a valuable tool for health care providers as
they strategize to improve their vaccination practices.
In addition to The Community Guide
tools, cultural changes are required.
Nurses in any setting are in an ideal
position to improve pneumococcal
immunization rates by creating an environment that focuses on understanding
the importance of vaccines. The nurses’
role in advocating for and assuring vaccines are available to all patients for
whom they are indicated cannot be
understated. Nurses should work collaboratively to establish plans to assure
that with every patient encounter: vaccination status is addressed, the vaccine
is administered appropriately, patients
are informed of the associated cost and
insurance coverage, and of the potential consequences of not receiving the
vaccination.
Conclusion
Pneumococcal polysaccharide
vaccine is safe and cost effective.
Barriers, such as patients not being
aware of, or confused by, the vaccination schedule and/or the lack of recommendation by a health care
provider, may contribute to the current low adherence to national health
goals. However, identifying barriers in
your organization and formulating
strategies to address them in clinic settings may minimize their impact.
Nurses must be knowledgeable about
the vaccine. Activities such as
enrolling to receive weekly newsletters
from the Immunization Action
Coalition, reviewing the ACIP guidelines, and staying abreast of local
health department announcements of
health trends can increase this knowledge base. Nurses should also incorporate assessing, advising and admin8 ViewPoint MARCH/APRIL 2014
istering the vaccine into daily routine
care. Clear communication of the vaccine risk and benefits by nurses is key
to improving patient knowledge and
acceptance of the pneumococcal vaccine. Furthermore, system changes
that encourage the consistent monitoring of vaccination schedules and
timely provision of vaccines would
also enhance the rate of vaccination
against streptococcus pneumonia. A
robust immunization program is a
regulatory and patient safety priority.
References
Atkinson, W.L., & Kroger, A.T. (2011).
Pneumococcal Polysaccharide Vaccine
(PPSV). Immunization Action Coalition
(IAC): Vaccine information for health care
professionals. Retrieved from http://
www.immunize.org/catg.d/p2015.pdf
Burns, I.T., & Zimmerman, R.K. (2005).
Immunization barriers and solutions.
The Journal of Family Practice, 54(1
Suppl.), S58-62.
Centers for Disease Control and Prevention
(CDC). (2011). Chapter 3: Infectious diseases related to travel. Retrieved from
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/pneumococcaldisease-streptococcus-pneumoniae.htm
Gooden, H.J. (2010). Missed opportunities:
Influenza and pneumonia vaccination in
older adults. Retrieved from http://
www.lung.org/assets/documents/
publications/lung-disease-data/
adult-vaccination-disparities.pdf
Johnson, D.R., Nichol, K.L., & Lipczynski, K.
(2008). Barriers to adult immunization.
The American Journal of Medicine, 121(7
Suppl 2), S28-35. doi:10.1016/j.
amjmed.2008.05.005
Merck and Company. (2013). Pneumovax
23 product insert March 2013. Retrieved
from http://www.merck.com/product/
usa/pi_circulars/p/pneumovax_23/pne
umovax_pi.pdf
Merck Global Health Division. (2013). Price
list effective February 26, 2013. West
Point, PA: Author.
National Foundation for Infectious Diseases.
(2013). Facts about pneumococcal disease and prevention in adults. Retrieved
from
http://www.adultvaccination.
com/professional-resources/pneumotoolkit/immunizer-fact-sheet.html
Ndiaye, S.M., Hopkins, D.P., Shefer, A.M.,
Hinman, A.R., Briss, P.A., Rodewald, L.,
... Willis, B. (2005). Interventions to
improve influenza, pneumococcal
polysaccharide, and hepatitis B vaccination coverage among high-risk
adults: A systematic review. American
Journal of Preventive Medicine, 28(5
Suppl), 248-279. doi:10.1016/j.
amepre.2005.02.016
Rangel, M.C., Shoenbach, V.J., Weigle, K.A.,
Hogan, V.K., Strauss, R.P., &
Bangdiwala, S.I. (2005). Racial and ethnic disparities in influenza vaccination
among elderly adults. Journal of General
Internal Medicine, 20(5), 426-431.
doi:10.1111/j.1525-1497.2005.0097.x
Szilagyi, P.G., Shone, L.P., Barth, R., Kouides,
R.W., Long, C., Humiston, S.G., ...
Bennett, N.M. (2005). Physician practices and attitudes regarding adult
immunizations. Preventive Medicine,
40(2),
152-161.
doi:10.1016/j.
ypmed.2004.05.010
Thomas, C.P., Ryan, M., Chapman, J.D.,
Stason, W.B., Tompkins, C.P., Suaya,
J.A., … Shepard, D.S. (2012). Incidence
and cost of pneumonia in medicare
beneficiaries. Chest, 142(4), 973-981.
doi:10.1378/chest.11-1160
U.S. Department of Health and Human
Services. (2010). Healthy people 2020.
Washington, DC: Office of Disease
Prevention and Health Promotion.
Retrieved from http://www.healthy
people.gov/2020/default.aspx
Melly Turner, BSN, RN-BC, is a Cardiology
Practice Nurse, Ambulatory Cardiology
Clinics, University of Virginia Health System,
Charlottesville, VA.
Cherie Parks, BSN, RN-BC, is a Cardiology
Practice Nurse, Ambulatory Cardiology
Clinics, University of Virginia Health System,
Charlottesville, VA.
Felicia Murphy, BSN, RN, is a Cardiology
Practice Nurse, Ambulatory Cardiology
Clinics, University of Virginia Health System,
Charlottesville, VA.
Laura Dick, BSN, RN-BC, is a Cardiology
Practice Nurse, Ambulatory Cardiology
Clinics, University of Virginia Health System,
Charlottesville, VA.
Cherie Chaney, MSN, RN, is a Cardiology
Practice Nurse, Ambulatory Cardiology
Clinics, University of Virginia Health System,
Charlottesville, VA.
Kathryn Ward, MSN, APRN, BC, CDE, is
a Medical Center Manager, Ambulatory
Cardiology Clinics, University of Virginia
Health System, Charlottesville, VA.
Suzanne M Burns, MSN, RN, ACNP,
CCRN, RRT, FAAN, FCCM, FAANP, is
Professor Emeritus, School of Nursing,
University of Virginia, Charlottesville, VA,
and a Consultant, Critical and Progressive
Care Nursing and Clinical Nursing
Research, Charlottesville, VA.
Acknowledgment: The authors wish to
thank Kirsten Gibson for her assistance in
using survey monkey as well as Dr. David R.
Johnson and Kim Lipczynski for permission
to use the Barriers to Adult Immunization
survey for consumers and health care
providers.
Between a Rock and a
Hard Place
Did you ever experience a dilemma while on a phone
with a patient? Has a question been posed that makes you
feel trapped? You may suddenly feel inept, tongue-tied, or
deficient. You may feel at a loss for the right response and
silence is not an option. You may find yourself between a
rock and a hard place.
This column will discuss three common questions
callers pose to nurses on telephones across the country in
all settings. The callers believe they are asking a reasonable
question, but experienced telephone nurses know that
these questions are riddled with risk. When answered
appropriately, the nurse will confidently maintain comfort
and feel competent and the patient or family member will
perceive that the question was expertly handled.
What will they do if I come in for an
appointment?
A patient requests to know what will be done during
an appointment or emergency room visit. This situation
occurs when you have completed your assessment and
have recommended that the patient be evaluated by a care
provider. The level of care may be emergent, urgent, or
routine. The conversation with the patient may have been
focused and straightforward. The disposition is evident.
Then when you are validating that patent’s follow-through,
the following question is expressed: “What will they do if I
come in for an appointment?”
When I was an inexperienced triage nurse, this question made me feel cornered. I considered responding in
one of two ways and neither seemed appropriate.
Option 1: Speculate. I could make an educated guess
about the various possibilities that could occur in an
emergency or exam room. I knew hypothesizing about
diagnostic testing or medications was not appropriate. I
would be setting both the patient and provider up.
Option 2: Respond to the caller by saying, “I don’t
know.” Patients and family members call us because they
are seeking our expertise and advice. If we direct someone
to leave the comfort of his or her home and come to an
urgent care or take off from work for an appointment, the
person will want to know what to expect from this option.
As health care costs have risen for most Americans, there is
more of an insistence to know how an evaluation will be
beneficial. If he or she has already been evaluated, the
patient may press even more for a rationale for another
visit. If the patient hears an uncertainty and ambiguity in
our direction, his or her confidence in our direction may
diminish.
Speculating and declaring no knowledge about the
contents of a visit are unsatisfactory responses. Although
telephone nursing includes assessment, problem solving,
information, education, and triaging symptoms and guidance to the appropriate level of care, it does not include
projecting the details of a visit. Through experience, I
developed a logical, suitable, and truthful response that
has always been positively received. Although it is a
lengthy response, it placates callers.
Best Option. When the caller would ask about what
would be done if he or she came in for a visit, my response
included details about the rooming process and provider
workflow:
When you come for your visit, you will be asked questions
during your rooming process. The provider will see you next
and ask more questions and examine you. Then, based upon
your responses and the examination, the provider will determine next steps. Ask questions. And if you think more or less
should be done, express your requests and concerns.
What do you think this is?
You have completed an assessment on a reported
symptom and the patient requests your insight into the
condition or disease that is causing the symptoms. If you
are an experienced nurse, you may be able to deduce what
the diagnosis could be. This question can lead to a scope
of practice slippery slope.
Option 1: Share your insights. If you answer and tell the
caller what his or her symptoms could be, you are
practicing beyond your scope of practice. For example, the
caller shares that she has a blistery rash that is linear and
unilateral. From education and experience, you may
deduce that the rash is shingles. If you tell the caller that
she has shingles, you have made a medical diagnosis.
Option 2: Respond to the caller by saying, “I don’t
know.” This is similar to the first scenario. If you say you
don’t know, your caller may lose confidence in your skill
and competence. Additionally, you may actually know
what he or she is experiencing.
Best Option. Choose your words carefully. Relaying any
hint of a medical diagnosis can jeopardize your license and
mislead the patient. The consequences may not be able to
be rescinded. This response promotes patient satisfaction
and keeps the nurse safely within scope:
I am a nurse and I cannot make medical diagnosis.
However, from what you have shared with me, your symptoms are serious and you need to have an appointment for the
provider to examine you and diagnose your condition. The
benefit of a face-to-face visit allows for a visual assessment,
which is vital in making a diagnosis.
Will I make it through the night?
I would get this response mainly at the end of the day
when I worked in a clinic or during an evening or night
shift when I worked in a call center. My assessment was
completed and the symptoms indicated home care or a
continued on page 12
WWW.AAACN.ORG 9
Please share your own evidence-based strategies that can help us
provide safer care in the ambulatory setting. Keep it simple as you address
a topic you are passionate about sharing. For our official “Submission
Tips,” visit www.aaacn.org/viewpoint. Share your questions, ideas, or submissions with Sarah Muegge at [email protected].
Cystoscope Reprocessing
Safety: One Practice’s
Experience
Our medical group performs more than 700 cystoscopies a year in the urology office. Because invasive procedures such as cystoscopies involve contact of a medical
instrument with a patient’s sterile tissue, one major concern is the risk for infection. According to the Center for
Disease Control and Prevention’s (CDC) Healthcare
Infection Control Practices Advisory Committee (Rutala,
Weber, & HICPAC, 2008), cystoscopes are considered
semi-critical medical devices and therefore, high-level disinfection (HLD) with chemicals is the minimal reprocessing
method recommended for killing microorganisms that
may be present on the cystoscope. Unfortunately, studies
cited in this same report show that compliance with established guidelines for disinfection and sterilization is poor
and most infections associated with reprocessing involve
HLD of semi-critical items. In fact, according to the CDC,
semi-critical items cause more health care-associated infections than critical or non-critical items (Rutala, Weber, &
HICPAC, 2008). Additionally, a study by Alfa and Howie
(2009) showed that the progressive accumulation of
biofilm through repeated rounds of inadequate reprocessing decreased the effectiveness of HDL. Following anecdotal reports of an increased incidence of UTIs by the urology nurse, the medical group knew we had to investigate
further. This article describes how our organization worked
to improved cystoscopy reprocessing to enhance patient
safety. The Institute for Healthcare Improvement
(http://www.ihi.org) is a great resource for those who
want more information about process improvement.
Registration for the site is free.
The issue was brought to the attention of the Medical
Director of Quality and Patient Safety who, in turn, spoke
to one of our infectious disease specialists and the urologists. Interprofessional collaboration is critical to the success of a process improvement (PI) project such as this
one. The urologists had not noticed an increase in UTIs,
but were not opposed to us looking into our processes.
They agreed to support the process improvement project,
but expressed concerns that patient flow and care not be
delayed or disrupted. The clinical staff (RNs and LPNs) had
misgivings because this was the first time they were
involved in a PI project and were concerned that they
would be blamed for something they were doing wrong if
a problem was found with the reprocessing procedure.
This reaction is fairly common among those who are unfamiliar with process improvement. To allay their concerns,
a brief overview of process improvement and the goal of
10 ViewPoint MARCH/APRIL 2014
improving processes and workflow related to reprocessing
the cystoscopes was explained.
As a first step, a literature review was conducted to
establish best practices (Clemens et al., 2009; Rutala,
Weber & HICPAC, 2008) in flexible cystoscope reprocessing. The product manufacturer’s user manual (Karl Storz
Endoskope, 2011) and the chemical disinfectant brochure
(Advanced Sterilization Products, 2011) were reviewed for
information specific to the flexible cystoscopes used in our
practice. Next we examined our current practice. Clinical
staff were shadowed for two days and the entire process
documented beginning with patient intake through
patient exiting. Staff were interviewed to understand the
training they received to assist with cystoscopy procedures
and cleaning equipment. Findings were documented in
detail, a gap analysis was performed comparing our current practice against best practices to identify problematic
areas, and the findings shared with the Medical Director of
Quality and Patient Safety, the urologists and the nursing
staff. Several major areas of concern were identified: 1) lack
of standardized processes for instrument reprocessing; 2)
lack of competency-based training and validation on flexible cystoscope reprocessing; 3) inefficient workflow
around reprocessing; 4) reprocessing logs that were not
kept up to date; 5) inappropriate storage of clean flexible
cystoscopes; and 6) inappropriate handling, disposal and
storage of the high-level disinfectant.
Next, we developed a plan to address the gaps. A
process map was developed to understand the workflow
around reprocessing. Our workflow analysis showed a
need to set up separate clean and dirty utility rooms, and
to create an auditory reminder to tell the staff when the
soaking phase was complete (over soaking can damage
the instrument) since staff do not stay in the reprocessing
room during the soak phase. Our low-tech solution to the
auditory reminder was a kitchen timer. The reprocessing
room is centrally located and within earshot of all the exam
rooms and the front desk. We also had safety concerns for
the staff, as the chemicals used in reprocessing are dangerous to humans. The utility room was already equipped
with a ventilation hood; therefore, staff education sessions
were focused on the safety risks to health care providers in
handling, disposal, and storage of the chemical disinfectants, correct use of the ventilation hood, and personal
protective equipment as well as relevant Material Safety
Data Sheets. Proper maintenance of reprocessing logs was
also emphasized.
Having recognized the skills gaps of the nursing staff,
we developed competencies that have become an essential part of staff education. The competencies cover the
entire process from start to finish, including identifying
which instruments we use, best practice recommendations
for initial cleaning and HDL, steps to protect our workforce
from exposure to chemical and potentially hazardous
materials, and safe disposal of HDL chemicals. Instrument
reprocessing via HDL is a multi-step process and it is important that each step occur in a specific order. To support this
step-by-step approach, we created and placed a laminated
poster of the steps in the reprocessing room. Completed
competency validation is kept on file for all staff involved in
instrument reprocessing documenting their skills to ensure
consistent evidence-based practice. We plan to do annual
staff competency validation and this will be done in mid2014.
Lastly, we developed a PI monitor tool to measure
compliance with completing the reprocessing logs. The
nurse manager completed the tool and evaluated the
results. Based on the results, remediation was needed to
ensure that the log was filled in completely and up to date.
Compliance with completing reprocessing logs is monitored periodically and the results are shared with the staff.
There is also a plan to develop a form in our electronic
medical record to improve nursing documentation.
Feedback from the physicians and nursing staff has
been very positive. As a result of this project, the nursing
staff report improved confidence in their ability to
reprocess the equipment and feel good that they are taking steps to ensure patient safety. Additionally, the cystoscopy PI project became the launch pad for additional
quality improvement work in our urology and GYN practices. We used the newly developed cystoscopy competencies to cross train other staff in cystoscope reprocessing
and as the basis for the development of competencies for
hysteroscope reprocessing. Obstetric and gynecological
(OB-GYN) physicians perform hysteroscopies in the urology procedure rooms. Our urology and OB-GYN nurses are
now cross-trained to assist with both cystoscopies and hysteroscopies. In the very near future, we will begin a PI project looking at patient safety and staff competency for urodynamics testing, another procedure performed by both
urology and GYN practices.
References
Advanced Sterilization Products. (2011). Cidex® high level disinfection
(Publication No. AD-110030-01-CT_A). Retrieved from
http://www.aspjj.com/emea/sites/www.aspjj.com.emea/files/pdf/
AD-110030-01-CT_A%20Manual%20Solution_CIDEX_LD_0.pdf
Alfa, M.J., & Howie, R. (2009). Modeling microbial survival in
buildup biofilm for complex medical devices. BioMed
Central Infectious Diseases, 9(56). Retrieved from
http://www.biomedcentral.com/1471-2334/9/56
Clemens, J.Q., Dowling, R., Foley, F., Goldman, H., Gonzalez, C.,
Tessier, C., … Young, E. (2009). Joint AUA/SUNA white paper on
reprocessing of flexible cystoscopes. Retrieved from
http://www.auanet.org/education/guidelines/flexiblecystoscopes.cfm
Karl Storz Endoskope. (2011). General reprocessing instructions for KARL
STORZ products (USA) (Publication No. PI-000035-20.1). Retrieved
from http://www.urologicservices.com/documentation/karl-storzgeneral-reprocessing-instructions.pdf
Rutala, W.A., Weber, D.J., & Healthcare Infection Control Practices
Advisory Committee (HICPAC). (2008). Guideline for disinfection
and sterilization in healthcare facilities, 2008. Atlanta, GA:
Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2
008.pdf
Peggy Evans, MSN, RN, is the Nurse Manager, Education and
Performance Improvement, Rutgers Robert Wood Johnson Medical
Group, New Brunswick, NJ. She may be contacted at
[email protected]
Health Care Reform
continued from page 3
CCTM model and competencies is now the basis for the
CCTM Core Curriculum text (Haas, Swan, & Haynes, in
press) and a series of modules that began in February 2014
to educate registered nurses working in ambulatory care.
The Core Curriculum text and CCTM course are designed to
assist ambulatory care nurses to develop the knowledge,
skills, and attitudes needed to successfully assume the role
of the RN working in CCTM.
The Core Curriculum is evidence-based and provides
cutting-edge methods to be used by the registered nurse
delivering care coordination. Alternatives to face-to-face
office visits are presented. For example, telehealth methods
are discussed in depth, such as the use of Skype® and telemonitoring. There is discussion of methods for interprofessional communication, interagency communication, and
measurement of outcomes.
True to the recommendations of the IOM report, The
Future of Nursing (2010), AAACN has provided a visionary
new role for registered nurses that will enhance access for
the newly insured and provide high quality care for all
patients served. For further information on the CCTM Core
Curriculum text and course, visit www.aaacn.org/cctm.
References
Affordable Care Act (2010). Read the law. Retrieved from
http://www.hhs.gov/healthcare/rights/law/index.html
Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory
care registered nurse competencies for care coordination and
transition management. Nursing Economic$, 31(1), 41-48.
Haas, S., Swan, B.A., & Haynes, T. (Eds.). (in press). Care coordination
and transition management core curriculum. Pitman, NJ:
American Academy of Ambulatory Care Nursing.
Institute of Medicine (IOM). (2010). The future of nursing: Leading
change, advancing health. Retrieved from http://
www.iom.edu/Reports/2010/The-Future-of-Nursing-LeadingChange-Advancing-Health/Recommendations.aspx
Ollove, M. (2014). Are there enough doctors for the newly insured?
Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/Stories/2014/January/03/doctor-shortage-primarycare-specialist.aspx
U.S. Department of Health and Human Services, Health Resources
Services Administration (HRSA). (2014). Shortage designation:
Health professional shortage areas & medically underserved
areas/populations. Retrieved from http://www.hrsa.gov/shortage
Sheila Haas, PhD, RN, FAAN, is a Professor, Niehoff School of
Nursing, Loyola University of Chicago, Chicago, IL. She can be
contacted at [email protected]
WWW.AAACN.ORG 11
Trials and Triumphs
continued from page 9
visit within 24 hours. Although the triage went smoothly
and I was confident in the direction, this question would
halt closing the call. What did the caller withhold? Was I
missing something? What did he or she not report?
Option 1: Stay the course. With a thorough assessment,
you could reassure the caller that the level of care is
appropriate. However, this option could lead to a
disastrous outcome if this was your caller’s way of letting
you that he/she did not report everything. Are you
overlooking his or her gut feeling?
Option 2: Panic. Assume that the patient needs 911 after
they utter a question that hints at a premonition of death.
If you assume impending doom, you may be executing an
unnecessary emergent response plan.
Best Option. This question is really quite easy to react to.
You may need to triage the symptoms again to ensure that
you have heard everything accurately. It is important to be
direct with the caller and ask the following open-ended
questions, What is concerning you about nighttime? What are
you experiencing that makes you uneasy about
homecare/waiting until tomorrow? Summarize what the
patient has reported to you and then say, You seem worried
about tonight, is there anything you or I have missed from
what you are experiencing?
Although the telephone triage process typically flows
smoothly, there will be occasions when the caller poses a
question that makes you feel cornered. Most of the times,
these show-stopping questions occur as you are wrapping
up. It is important that there is good connectivity during
the call, but also at the end of the call. Do not mentally disconnect before the call ends. Stay focused and allow for
those end-of-the-call inquiries. Be prepared for these types
of questions and be proactive in preparing responses that
relay not only direction, but confidence, safety, and quality of care. This is the art of telephone triage nursing.
Kathryn Koehne, BSN, RN-BC, C-TNP, is a Nursing Systems
Specialist, Department of Nursing, Gundersen Health System, and
a Professional Educator, Telehealth Triage Consulting, Inc. She can
be contacted at [email protected]
Sensitive Indicators Task Force
continued from page 1
important to patients and their families; impact organizational effectiveness and reimbursement; relevant to
AAACN member practice, available in standardized or
endorsed metrics; adequate in volume and repeated
over time; and readily accessible or already available in
electronic databases.
“The transition of health care from the inpatient to
the outpatient setting has led to challenges with access
to care and coordination of services, and has increased
the complexity of care delivered outside the hospital
walls. This shift has dramatically increased the need for
professional nursing services…. Ambulatory RNs facili12 ViewPoint MARCH/APRIL 2014
tate patient care services by managing and individualizing care for patients and their families, who increasingly require assistance navigating the complex health care
system…professional nursing services provide support
with decision-making, patient education, and coordination of services” (AAACN, 2010, p. 1).
The AAACN task force is currently collaborating with
other groups, such as the American Nurses Association
(ANA) and RN leaders within the U.S. Army, that have
similar interest in the value of ambulatory nursing. The
task force was invited and seven members attended an
ANA Summit in January 2014 to further the ambulatory
nursing sensitive indicator agenda. The task force will
continue its work and will actively engage the membership in further dialogue at the upcoming AAACN
Annual Conference.
If you’re attending the New Orleans conference, we
encourage you to attend the Town Hall, Wednesday,
May 21, at 8 a.m., (session 201) and voice your ideas
on ambulatory NSIs. Additionally, join the presentation
by task force Chair Dr. Birmingham on Wednesday, May
21, at 10:30 a.m. (session 213).
Task Force Members: Sharon Eck Birmingham, DNSc, MA,
BSN, RN, Chair; Nancy May, MSN, RN-BC, NEA-BC, AAACN
Board Liaison; Baylor Scott and White Health; Rosemarie
Battaglia, MSN, RN, Children’s Hospital at the Medical University
of South Carolina; Nena Bonuel, PhD, RN, CCRN, CNS, ACNSBC, Harris Health; Diane Storer Brown, PhD, RN, CPHQ, FNAHQ,
FAAN, Collaborative Alliance for Nursing Outcomes (CALNOC);
Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC, VA System, Florida;
Eileen Esposito, DNP, RN-BC, CPHQ, Catholic Health Services of
Long Island; Kris Grayem, MSN, CNP, RN, Akron Children’s; Ann
Jacobson, PhD, CNS, ACNS-BC, Kent State University; Kathleen
Martinez, BSN, RN, CPN, Children’s Hospital Colorado; Peg
Mastal, PhD, MSN, RN, Past President of AAACN; Ann Marie
Matlock, RN, DNP, NE-BC, National Institutes of Health Clinical
Center; Mary Morin, RN, NEA-BC, RN-BC, Sentara Medical
Group; Catherine Rhodes, MSN, CRNP, WHNP-BC, RNC-OB,
SANE-A; Karen Seifert, MSN, RN, CDE, Mayo Clinic Arizona;
Rachel Start, MSN, RN, Rush Oak Park Hospital and Rush System
for Health; Deborah Tinker, MSN, RN, CENP, University of
Wisconsin Hospitals and Clinics.
References
American Academy of Ambulatory Care Nursing (AAACN).
(2010). Position statement: The role of the registered nurse in
ambulatory care. Pitman, NJ: Author.
Donabedian, A. (1966). Evaluating the quality of medical care.
Milbank Memorial Fund Quarterly, 44(3 Suppl), 166-206.
Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory
care registered nurse competencies for care coordination and
transition management. Nursing Economic$, 31(1), 44-49, 43.
Rachel Start, MSN, RN, is Director, Magnet Program, Rush Oak
Park Hospital and Rush System for Health, Chicago, IL. She may be
contacted at [email protected]
Sharon Eck Birmingham, DNSc, MA, BSN, RN, is Chief
Nursing Executive, Eck Birmingham & Associates, Hillsborough,
NC, and Adjunct Faculty at the Universities of North Carolina,
Iowa, Colorado, and Yale. She is Chair of the AAACN Nurse
Sensitive Indicators Task Force, and may be contacted at sharon
[email protected]
Researching the Scope of
Practice for Medical
Assistants
In our current health care system, ambulatory care
nursing must focus work efforts on delivering safe, effective, and efficient patient care while utilizing cost effective
measures within staffing models. This drives ambulatory
care to place the right person, with the right skill set in the
right position. Adding medical assistants to the staffing mix
assists with cost containment but opens many questions as
to what the medical assistant can legally perform in the
ambulatory care setting. This column will review how to
research scope of practice, appropriate delegation, state
legislation, rules and regulation that are needed to guide
our decisions related to the utilization of medical assistants.
Before determining what tasks the medical assistant
can perform, one must first understand what encompasses
a scope of practice. The American Academy of Ambulatory
Care Nursing (AAACN) defines Scope of Practice as the
“procedures, actions and processes permitted for a
licensed individual and is limited to that which the law
allows for specific education and experience, and specific
demonstrated competency” (Paschke, 2013, p. 38). The
definition refers to the “licensed individual.” Currently
medical assistants are not licensed in the United States and
there is not a uniform, standard, or national definition of a
medical assistant’s scope of practice. Medical assistants
work under the direct supervision of a licensed physician
who has the authority within their state to delegate certain
medical tasks and procedures. Maryland’s definition of
physician to medical assistant delegation is typical of most
states, whereby the delegating individual is a “physician
possessing an active license to practice medicine in the
State who directs an assistant to perform technical acts”
(Code of Maryland Regulations, 2013). This leaves each
state to determine scope of practice laws along with any
educational requirements they deem necessary for the
medical assistant. These laws and scopes vary greatly
across the country from state to state.
In California, medical assistants are not licensed, certified or registered by the State (Medical Board of California,
2010). However, the physicians’ malpractice insurance carriers may require medical assistants to be certified by a private or national organization. The legislature recognizes a
core scope of practice for medical assistants and the
Medical Board has set forth minimal training requirements
for procedures that include: intradermal, intramuscular,
and subcutaneous injections, skin testing and venipuncture
for withdrawing blood (Medical Board of California, 2010).
“In every instance, prior to administration of medicine by
a medical assistant, a licensed person such as a supervising
physician, podiatrist or another appropriate licensed per-
son, must verify the correct medication and dosage”
(Medical Board of California, 2010). For additional tasks,
the medical assistant shall receive training, as necessary, in
the judgment of the supervising physician, podiatrist or
instructor, to assure competence in performing that service
at the appropriate standard of care (Medical Board of
California, 2010). These tasks include: performing EKGs,
applying and removing bandages and dressings, applying
orthopedic devices, removing sutures or staples from
superficial incisions or lacerations, ear lavages, providing
patients with information and instructions as authorized by
the physician, performing and recording vital signs, performing simple lab and screening test, and cutting the nails
of healthy patients (McCarty, 2012).
In South Dakota, the regulations states, “No person
may practice as a medical assistant unless that person is
registered with the Board of Medical and Osteopathic
Examiners” (South Dakota Board of Nursing, 2012). To
register with the Board, the applicant must have “graduated from an accredited school or a school which meets standards similar to an accredited school and has met other
qualifications established by the Board of Medical and
Osteopathic Examiners and the Board of Nursing” (South
Dakota Board of Nursing, 2012). Once the standard is met,
the medical assistant may administer medications by unit
dose, which means “medication prepared in the exact
amount, in an individual packet, for a specific patient”
(South Dakota Board of Nursing, 2012). They may also
report diagnostic lab findings to patients only after appropriate interpretation by the physician, provide education
information to the patient, perform EKG’s, glucose testing,
distribute pre-printed information to the patient on medications and inhalers, apply ace bandages and splints to
extremities, may only perform suprapubic catheterizations
involving an established fistula, skin testing performed by
intradermal or scratch techniques, telephone prescriptions
to a pharmacy pursuant to their supervising physician’s
written or verbal order, administer medications via inhalation route as long as the supervising physician assures
appropriate training, competence, and assumes ultimate
responsibility for administration of such drugs (South
Dakota Board of Nursing, 2012). Medical assistants in
South Dakota may not inject insulin, perform arterial withdrawal of blood, provide patient education, health teaching or counseling, administer medication which requires
calculations, or perform irrigation for ostomy/stoma care
(South Dakota Board of Nursing, 2012).
Under Florida statutes, medical assistants are not
required to be certified to be employed but may be certified by the American Association of Medical Assistants or as
a Registered Medical Assistant by the American Medical
Technologists. Some of the duties they may perform under
the direct supervision of a licensed physician include: performing aseptic technique, taking vital signs, performing
venipuncture and non-intravenous injections, observing
and reporting signs and symptoms, administering basic
first aid, assisting with examinations or treatments, collecting routine lab specimens as directed by the physician and
performing basic laboratory procedures, administering
WWW.AAACN.ORG 13
medications as directed by the physician, performing office
procedures and general administrative duties, and performing dialysis procedures, including home dialysis (The
Florida Senate, 2013).
In Texas, physician written delegation allows for medical assistants to administer immunizations and designated
medications to patients by written physician orders. The
Texas Medical Association requires physicians to assure
education and competency for designated tasks have been
met. Licensed nurses provide education, skill validation,
and supervision. The Texas Board of Nursing Rule 224.10
Supervising Unlicensed Personnel Performing Tasks
Delegated by Other Practitioners states “the RN (a) (1) verifies the training of the unlicensed person; (2) verifies that
the person can properly and adequately perform the delegated task without jeopardizing the client’s welfare; and
(3) adequately supervises the unlicensed person. (b) If the
RN cannot verify the unlicensed person’s capability to perform the delegated task, the RN must communicate this
fact to the licensee who delegated the task” (Texas Board
of Nursing, 2013, p. 160). For example, Kelsey-Seybold
Clinic in Houston was able to utilize the physician delegation rules, combined with the registered nurses rules and
regulations for supervising unlicensed personnel to create
a program to ensure competency. This program provided
the opportunity to reshape the staffing model within the
clinic system. This program was implemented in primary
care in 2009 and has proven to be very successful. Moving
forward, the program has expanded to some specialty
areas and there are plans to expand in the near future.
To discover the scope of practice for each individual
state, one must research state laws, health codes, statutes,
nursing boards, medical boards, and relevant practice acts.
Delegation rules are important to review and consider, as
well as, the type of supervision required by each state.
Utilizing search engines with your state’s name, physician
delegation or state’s name and scope of practice will yield
a vast amount of information. For example, the American
Association of Medical Assistants (AAMA) currently has
links posted on their web-site for medical assistant tasks in
the following States: Arizona, California, Florida, Illinois,
Maryland, New Jersey, Ohio, South Dakota, and Virginia
(American Association of Medical Assistants, 2013). Also on
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14 ViewPoint MARCH/APRIL 2014
the AAMA site there is an area to enter questions you may
have and they will provide a response. The Medical
Assistant Training site will provide links to all of the state’s
Medical Boards in the United States.
What tasks can be delegated to the Medical Assistant
rest with state regulations, the employing organization,
and the licensed providers supervising their work. The state
rules and regulations provide a framework as to what can
be delegated; however, if an organization wants to further
limit these tasks, it is their right to do so. Providers can also
decide to limit what tasks they are comfortable with delegating. In all cases, competency of that individual Medical
Assistant is the responsibility of the provider and the
employing organization.
References
American Association of Medical Assistants (AAMA). (2013). State scope of
practice laws. Retrieved from http://www.aama-ntl.org/employers/statescope-of-practice-laws
Code of Maryland Regulations. (2013) Retrieved from http://
www.dsd.state.md.us/comar/comarhtml/10/10.32.12.02.htm
Florida Senate, The. (2013). The 2013 Florida Statutes. Retrieved from
http://www.flsenate.gov/Laws/Statutes/2013/458.3485
McCarty, Esq, M.N. (2012). The lawful scope of practice of medical assistants – 2012 update. AMT Events. Retrieved from
http://www.americanmedtech.org/NewsAdvocacy/View/tabid/95
/ArticleId/14/The-Lawful-Scope-of-Practice-of-Medical-Assistants2012-Update.aspx
Medical Assistant Training 101. (2013). Medical assistants scope of practice
by state. Retrieved from http://www.medicalassistanttraining
101.com/state-medical-boards
Medical Board of California. (2010). Retrieved from http://www.
mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/
Medical_Assistants_FAQ.aspx
Paschke. (2013). Paschke, S.M. (2013). Ambulatory care operations. In C.B.
Laughlin (Ed.), Core curriculum for ambulatory care nursing (3rd ed.).
Pitman, NJ: American Academy of Ambulatory Care Nursing.
South Dakota Board of Nursing. (2012). Medical assistants. Retrieved from
http://doh.sd.gov/Boards/Nursing/medasst.aspx
Texas Board of Nursing. (2013). Rules and regulations. Retrieved December
11, 2013, from http://www.bne.state.tx.us/
Mary-Ellen Gregory, RN, is a Clinical Educator, Clinical Education
Department, Kelsey-Seybold Clinic, Houston, TX. She may be contacted at [email protected]
Virtually Attend the
39th Annual Conference
By the time you read this copy of ViewPoint, it is probably too late for you to attend the New Orleans conference. But don’t worry! The audio recordings and handouts
from all sessions offered at the conference will be available
about six weeks after the conference in the AAACN Online
Library (www.aaacn.org/library). You may purchase individual sessions or a package of all sessions. Prices include
continuing education credit. Once you make a purchase,
you have permanent access to those sessions. Past conferences, ViewPoint articles, and webinars are also in the
Library. We encourage you to browse the Online Library for
topics of interest to you. If you know someone who attended the conference, ask if he or she will share content with
you. Conference attendees can each offer two colleagues
access to the conference sessions for free.
● Colorectal cancer is the third most common cancer among
Americans with a lifetime risk of 1 out of 10 (5%). Check out
the information on screening and which patients are at the
highest risk at the American Cancer Society website
(http://www.cancer.org/cancer/colonandrectumcancer/).
● Poison control is not just for children who search in medicine cabinets. The American Association of Poison Control
Centers report that adults account for 92% of poison-related deaths. For more information and poison prevention tips
for adults, visit http://www.aapcc.org/prevention/adults/
● Health disparity issues that are different among groups
of people such as women, the elderly, children, and the like
are important for nurses to be familiar with in ambulatory
care practice. To review health disparities and research on
diverse groups, refer to MedlinePlus at http://www.nlm.
nih.gov/medlineplus/healthdisparities.html
● Peripheral neuropathy can be a painful, chronic condition for those undergoing chemotherapy or with diabetes
and other neurological conditions. For more information,
visit the National Institute for Neurological Disease and
Strokes (http://www.ninds.nih.gov/disorders/peripheral
neuropathy/detail_peripheralneuropathy.htm).
Carol Ann Attwood, MLS, AHIP, MPH, RN,C, is a Medical
Librarian, Patient Health and Education Library, Mayo Clinic
Arizona, Scottsdale, AZ. She can be contacted at
[email protected]
2014 Challenge Underway
The AAACN annual Member-Get-A-Member recruitment program kicked off April 1. The program invites
members to recruit new members to the association by
explaining the value they’ll get from membership, as well
as by sharing all the benefits of membership.
Recruiting is easy. Download and print the membership application from the website (www.aaacn.org), enter
your name in the “referred by” section, make a few copies,
and then talk to your colleagues about joining and give
them the application. You can also direct your colleagues
to the website and ask them to place your name in the
“referred by” section of the online application.
You could be the winner of the monthly prize of a $50
AAACN certificate. When the program closes at the end of
2014, you are also eligible to win a $100 certificate for
recruiting 3 or more members. One member will receive
FREE registration to the 2015 Orlando conference for
recruiting the most members (at least 5 or more).
President’s Message
continued from page 2
around the country, or the recorded course offered in the
Online Library, the series provides other options for those
interested in becoming certified in ambulatory care.
AAACN continues to collaborate with the American
Nurses Association (ANA) on the development of Nurse
Sensitive Indicators (NSI) for ambulatory care. The AAACN
NSI Task Force, begun last year, has had an ANA staff member participating since its inception. Seven representatives
from AAACN attended a national Summit in January and
served as subject matter experts in the discussion and identification of a preliminary set of indicators that are meaningful in ambulatory care. See the cover article to learn
how this important work is developing.
Care Coordination and Transition Management
(CCTM) has been a major focus of AAACN’s efforts and
resources for the past few years. Four separate expert panels consisting of members and non-members collaborated
on this project. One group reviewed the existing literature
on care coordination, a second group identified nine core
dimensions and created a table of evidence, and the third
group defined core competencies for each of the dimensions. The work continued by a fourth panel with the
development of a core curriculum for CCTM with expected publication in June and the CCTM course, which
debuted with the Introductory module in February.
Because Care Coordination has been a topic of discussion
in all health care environments, especially since the inception of the Patient Protection and Affordable Care Act,
resources to assist nurses and organizations in preparing
for and creating these roles for registered nurses have been
sporadic. The availability of the CCTM core curriculum and
course to all nurses and health care organizations will help
to define the roles and skills required to serve in this important position now and in the future.
As my presidency is winding down and I reflect on all
that has happened this past year, I am grateful for the
members of this organization who have given of their time
and talent to accomplish all of the things mentioned
above. It is an honor to represent such a dedicated and
committed group of individuals who find or make time in
their busy work and personal lives to impact the lives of
patients and colleagues through their work on these projects and initiatives. The word is out…we ARE ambulatory
care!
Susan M. Paschke, MSN, RN-BC, NEA-BC, is Chief Quality
Officer, Visiting Nurse Association of Ohio, Cleveland, OH. She may
be contacted at [email protected]
WWW.AAACN.ORG 15
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Volume 36, Number 2
ViewPoint is published by the
American Academy of Ambulatory
Care Nursing (AAACN)
AAACN Board of Directors
President
Susan M. Paschke, MSN, RN-BC, NEA-BC
President-Elect
Marianne Sherman, MS, RN-BC
AAACN is a welcoming, unifying community for registered nurses in all ambulatory care settings.
Our mission is to advance the art and science of ambulatory care nursing.
Immediate Past President
Suzi Wells, MSN, RN
Director/Secretary
Judy Dawson-Jones, MPH, BSN, RN
Director/Treasurer
COL (Ret.) Carol A.B. Andrews, PhD, RN-BC,
NE-BC, CCP
Directors
Debra L. Cox, MS, RN
Nancy May, MSN, RN-BC
CAPT (Ret.) Wanda C. Richards, MPA,
MSM, BSN
Executive Director
Cynthia Nowicki Hnatiuk, EdD, RN, CAE, FAAN
Director, Association Services
Patricia Reichart
AAACN ViewPoint
www.aaacn.org
Editor
Kitty M. Shulman, MSN, RN-BC
Editorial Board
Sharon Eck Birmingham, DNSc, MA, BSN, RN
Patricia (Tricia) Chambers, BHScN, DC, RN
Virginia Forbes, MSN, RN, NE-C, BC
Liz Greenberg, PhD, RN-BC, C-TNP
Patricia L. Jensen, MS, RN-BC
Manuscript Review Panel
Ramona Anest, MSN, RNC-TNP, CNE
Deanna Blanchard, MSN, RN
Ami Giardina, MHA, BSN, RN
Jennifer Mills, RNC, CNS-BC
Sarah Muegge, MSN, RNBC
Becky Pyle, MS, RN, B-C
Pamela Ruzic, MSN, RN-BC
Assanatu (Sana) I. Savage, PhD, DNP, FNP-BC
Laurel Stevens, MSN, RN, NEA-BC
Janis S. Tuxbury, DNP, FNP-BC
Managing Editor
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Editorial Coordinator
Joe Tonzelli
Layout Designer
Bob Taylor
Education Director
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Marketing Director
Tom Greene
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Call for Abstracts for the 2015
Orlando Conference
You are invited to submit an oral or poster abstract
for the 40th AAACN Annual Conference, April 15-18,
2015, to take place at the Hilton Orlando. Share your
knowledge, best practices, and research with your colleagues. Presenters receive $100 off their registration fee.
Oral presenters also receive an honorarium. The deadline
for oral presentations is May 30, 2014, and the poster
deadline is December 15, 2014. Obtain the abstract submission criteria from the Events section of our website at
www.aaacn.org.

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